Treatment of postpartum haemorrhage: NATA consensus statement

Transcription

1 Treatment of postpartum haemorrhage: NATA consensus statement Jakob Stensballe MD, PhD, Consultant Anaesthetist & Transfusion Specialist Chair of Scientific Committee, NATA Section for Transfusion Medicine, Capitol Region Blood Bank & Department of Anaesthesiology, Centre of Head and Orthopaedics Trauma Centre, Rigshospitalet, Copenhagen University Hospital COI: None

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4 Prevention and Treatment of Postpartum Haemorrhage (PPH) Focus on Patient Blood Management A multidisciplinary expert meeting organised by NATA in collaboration with the International Federation of Gynecology and Obstetrics (FIGO), the European Board and College of Obstetrics and Gynaecology (EBCOG), the European Society of Anaesthesiology (ESA), and the World Health Organization (WHO)

5 Marie-Pierre Bonnet MD PhD Department of Anaesthesia and Intensive Care Medicine Cochin University Hospital Paris, France Edoardo De Robertis MD PhD ESA representative Associate Professor of Anaesthesia & Intensive Care Department of Neurosciences, Reproductive and Odontostomatologic Sciences University Federico II, Naples, Italy Groupe Hospitalier Cochin-Broca- Hôtel Dieu Assistance Publique des Hôpitaux de Paris Paris, France Stefan Hofer MD MHBA Professor Department of Anesthesiology University of Heidelberg Heidelberg, Germany Wolfgang Holzgreve MD MBA FIGO Representative Professor of Gynaecology and Obstetrics Medical Director and CEO University Hospital Bonn Bonn, Germany Beverley J. Hunt MB FRCP FRCP Anne-Sophie Ducloy-Bouthors MD MD Pole d Anesthésie-Réanimation Professor of Thrombosis and Academic Hospital Lille Haemostasis Lille, France King s College Guy s & St Thomas Hospital François Goffinet MD PhD London, UK Department of Obstetrics and Gynecology Manuel Muñoz MD PhD Port-Royal Maternity Professor of Perioperative Transfusion Medicine Department of Surgical Sciences, Biochemistry and Immunology School of Medicine, University of Málaga, Spain Jacky Nizard MD PhD EBCOG Representative Department of Obstetrics and Gynecology Groupe Hospitalier Pitié Salpêtrière Université Pierre et Marie Curie Paris, France Olufemi T. Oladapo MD MBBS MPH FWACS UNDP-UNFPA-UNICEF-WHO World Bank Special Programme of Research, Development and Research Training in Human Reproduction Department of Reproductive Health and Research World Health Organization Geneva, Switzerland Charles-Marc Samama MD PhD ESA Scientific Committee Chairperson Professor and Chairman Department of Anaesthesia and Intensive Care Medicine Cochin University Hospital Paris, France

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7 PBM program We recommend hospitals to have a Patient Blood Management (PBM) program (1.B)

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9 Primary outcome - mortality 9 trials with lower risk of bias, n=5707 Holst et al. BMJ 2015

10 WOMB Trial spph (> 1000 ml) median 1500 ml n=521 Inclusion : Hb 5-8 g/dl RBC Tx to > 8.5 g/dl vs. No-RBC-Tx (7.5 g/dl) No difference after 6 weeks (median 10 g/dl) Primary outcome : Physical fatigue no difference! PRICK et al. BJOG 2014

11 Hb 7.0 g/dl

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13 PBM program We recommend monitoring fibrinogen levels early in severe ongoing PPH in order to consider fibrinogen substitution at levels < 2 g/l (1.C)

14 Hiippala et al s landmark paper Resuscitation induced fibrinogen deficiency Hiippala ST et al., Anesth Analg. 1995

15 0.47 [0.31,0.71]

16 Non-severe PPH Severe PPH

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18 Wikkelsø et al

19 RCT N = g fibrinogen in patients needing second line uterotonics Primary endpoint - composite patients losing at least 4 g/dl of Hb, and/or requiring least 2 units of RBC in 48 h

20 RCT N = 60 with PPH > 1500 ml (ongoing) ROTEM goal-directed therapy Trigger: < 3.0 g/l (FIBTEM A5 < 16 mm). Goal: > 4 g/l (ROTEM FIBTEM A5 > 23 mm) Primary outcome: Total number of allogeneic blood products

21 Functional Fibrinogen TEG / FIBTEM ROTEM MA FF 6.3 mm (normal values 14-24)

22 PBM program We recommend monitoring fibrinogen levels early in severe ongoing PPH in order to consider fibrinogen substitution at levels < 2 g/l (1.C)

23 Massive uncontrollable ukontrollabel

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26 Massive uncontrollable 1:1:1

27 8 min Holcomb et al. JAMA 2015 Holcomb et al. JAMA 2015

28 Fewer advanced interventional procedures OR 1.25 [ ]; P = the whole cohort OR 1.58 [ ]; P = patients > 1 FFP

29 Viscoelastic Haemostatic Assays (VHA) Whole blood analysis TEG /ROTEM Measures the viscoelsatical properties of the clot Multiple endpoints reflecting clot formation, strength & degradation Real-time (15 min.)

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31 My points PPH is a worldwide problem PPH treatment should be initiated early (500 ml) and by a multidisciplinary team in stepwise management Algorithms can improve outcome